AACN Advanced Critical Care Volume 25, Number 4, pp. 326–329 © 2014, AACN
Creating a Healthy
Workplace
Nancy Blake, RN, PhD, CCRN, NEA-BC Department Editor
Reducing Worker Fatigue to Create a Healthy Work Environment Nancy Blake, RN, PhD, CCRN, NEA-BC Kay Gilmore, RN, MN Phan Dang, RN, MN Dan Villareal, RRT, MBA
R
ecent research about fatigue in health care has motivated nurses and hospital administrators to look at ways to manage the problem. This column examines a few relatively recent studies and alerts about the problem of fatigue.1–5 Defining Fatigue and Its Implications Ironically, Ben Franklin, founder of our nation’s first hospital, Pennsylvania Hospital, identified fatigue as a common health complaint.6 However, fatigue is one of the most difficult terms to define, and it is a symptom of many different conditions. Fatigue is generally defined as a feeling of lack of energy. It is not the same as sleepiness, but the desire to sleep may accompany fatigue.2 The American College of Occupational and Environmental Medicine’s (ACOEM’s) Task Force on Fatigue Risk Management provided us with an extensive review of fatigue and how we can reduce its risk to provide a balanced, healthy work environment.2 Evidence suggests that shift work associated with extended hours increases the risk for fatigue. Moreover, fatigue risk factors increase the likelihood of apathy, which is common in today’s shift workers, interfering with their productivity and performance.2 However, hours-of-service is not the only contributing factor that must be addressed. We must also consider workers’ time spent sleeping at home and the availability of rest at work. The Joint Commission reviewed the impact of fatigue on health care workers as well as factors that contribute to fatigue and the inherent increased risk to patients, and made important evidence-based recommendations in a Sentinel Event Alert1 published in December 2011. The alert presented clear evidence that nurses who work shifts of 12.5 hours or longer are at greater risk for errors and occupational injuries.1 This alert emphasizes the importance of developing evidence-based practice surrounding the issue of worker fatigue with those working 12.5 hours, hours of sleep, and truly addressing the culture surrounding this issue.
Nancy Blake is Director, Critical Care Services, Children’s Hospital Los Angeles, 25720 Oak Leaf Court, Valencia, CA 91381 ([email protected]). Kay Gilmore is Manager, Cardiovascular Acute Unit, Children’s Hospital Los Angeles, Valencia, California. Phan Dang is Manager, Acute Rehab, Children’s Hospital Los Angeles, Valencia, California. Dan Villareal is Manager, Respiratory Care, Children’s Hospital Los Angeles, Valencia, California. The authors declare no conflicts of interest. DOI: 10.1097/NCI.0000000000000052
326 Copyright © 2014 American Association of Critical-Care Nurses. Unauthorized reproduction of this article is prohibited.
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Creating a Healthy Workplace
Extended Work Hours Are extended work hours worth the risk? Industrial research indicates that worker productivity declines after 10 to 12 hours of work. Currently, about 75% of nurses work 12-hour shifts. Fatigue and sleep deprivation are linked to decreased vigilance, memory, information processing, reaction time, and decision making.3 US Army studies show that staying awake for 17 hours is equivalent to a blood alcohol level of 0.05%, and staying awake for 24 hours is equivalent to 0.10%.3 The California legal limit is 0.08%. The American College of Graduate Education restricts resident duty hours to 80 hours per week. Truck drivers are limited to 11 hours behind the wheel.3 The Federal Aviation Administration restricts pilot actual flight time to 16 hours.3 Railroad workers are required to take a 10-hour break before a new shift.3 A German study shows that injuries increase exponentially after the ninth hour of work.4 Work schedules can affect the sleep-wake cycle. Working extended hours can lead to musculoskeletal injuries. Blood-borne pathogen exposure increases during the last 2 hours of a 12-hour shift, and longer shifts increase burnout and job dissatisfaction. Nurses working 10 hours or more are 2½ times more likely to experience burnout.4
National Recommendations Worker alertness is partially dependent on the organization’s ability to develop and implement a Fatigue Risk Management System (FRMS) that will best fit the work environment. Thus, a fatigue risk management plan is essential for a healthy work environment. ACOEM Task Force key recommendations for a robust FRMS include 6 core components.2 See Table 1 for the core components with examples. The process for internal and external auditing of an FRMS can result in corrective actions for the organization through a continuous improvement process aimed at employee safety.2 The more complex the organization, the more robust the quality improvement process needs to be to prevent systems issues. Integration of an FRMS with other safety and health management systems is important. Addressing fatigue addresses safety for both patients and staff. If implemented correctly, a fatigue avoidance
Shift Work and Sleeplessness Scott et al5 found that shift work was associated with higher errors. Long work hours coupled with poor sleep are riskier work conditions (eg, 16-hour shifts returning to work with less than an 8-hour break). Drowsiness is not confined to the night shift. Alarmingly, 63% of the nurses studied described drowsy driving. Multiple errors or near misses were described when nurses stated that they were drowsy. If working over 16-hour shifts, staff nurses were 3 times more likely to make errors.5 In a more recent study by Scott et al,7 critical care nurses described that they were more likely to have clinical decision regret if they have inadequate sleep. When nurses make patient care decisions when they are sleepy, and the outcomes of these decisions are less desirable or unfavorable, negative affective emotions can surface that manifest as decision regrets. These decision regrets are failure to adhere to standard of practice, failure to be a patient advocate, failure to ensure patient safety, impaired cognition, failure to communicate in a professional manner, and negative affective responses.7
Table 1: Core Components of a Fatigue Risk Management System2 With Examples Core Component
Examples
Safety and Management Policy
This could include information on hours worked, structures, policies, practices, and shared responsibilities of staff and management.
Risk Management
Preventing human errors (managing sleep) and systems issues (staffing levels and appropriate amount of light)
Reporting
Attendance, safety and health metrics, the use of possible tools to assess fatigue
Incident Investigation
Assessing details related to fatigue, scheduling, staffing, and environment at the time of incident
Training and Education
Training about fatigue management as a joint responsibility as well as how much sleep the employee should get, and staffing and scheduling practices
Internal and external auditing
Internal auditing of incidents (eg, medication errors) and external auditing by an expert in occupational health
327 Copyright © 2014 American Association of Critical-Care Nurses. Unauthorized reproduction of this article is prohibited.
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Creating a Healthy Workplace
W W W .A A CNA D VA NCE D CRIT ICA LCA RE .COM
program can result in a system to maintain worker alertness. ACOEM also states that managing fatigue is a shared responsibility between the organization and the employee.2 Therefore, the employee plays a critical role. Getting adequate sleep requires attentive planning of work schedules so that “he or she does not start work with 8 or more hours of continuous wakefulness before start of duty.”2(p234) If the employee’s circumstances preclude sufficient sleep for any reason, then the employee has the responsibility to report or notify his or her manager. An organization’s FRMS should have 5 key elements to protect against errors from fatigue, including balance between workload and staffing, appropriate shift scheduling, employee fatigue training and sleep disorder management, workplace management environment design, and fatigue monitoring and alertness for duty. The organization must have a system of determining the effect of staffing and workload levels on the hours the employee is on service. A robust scheduling management system can track an employee’s number of scheduled days and number of hours worked. This system will proactively protect against fatigue.2 The American Nurses Association recently released the first draft of its position statement “Addressing Nurse Fatigue to Promote Safety and Health.” The final recommendations should be released soon, and it is important that hospital administrators and nurses implement the recommendations that come from a committee of experts who have done much of the research on fatigue in hospitals themselves. It is also important for nurses to be aware of the recommendations of their specialty organizations on this topic. The National Association of Neonatal Nurses has a position statement,8 as does the Association of periOperative Registered Nurses,9 which recommends that nurses work no more than 12 hours in a day and no more than 60 hours in a 7-day period. This recommendation addresses the on-call nature of their business.9 Organizational Commitment Among the actions recommended for all organizations is to assess the organization for fatiguerelated risks.1 In addition to reviewing pertinent policies to ensure that fatigue is addressed, organizations need to secure data related to the extent of off-shift hours and consecutive shifts. Also, the high-risk nature of hand-offs
for fatigued workers at the end of shifts of 12.5 hours (or more) must be recognized, and processes and procedures put into place to ensure that patients are protected. Soliciting staff input into the design of work schedules to minimize potential fatigue seems simple, but it is of utmost importance. The creation and implementation of a fatigue management plan not only recognizes the challenges but takes proactive steps to develop strategies for fighting fatigue. This plan, along with staff education about sleep hygiene and the effects of fatigue on patient safety, can benefit all organizations. In addition, building a culture of safety surrounding fatigue is an enormous opportunity for all health care organizations, as many have had “a culture of working long hours and the impact of fatigue has not been a part of our consciousness.”1 The Joint Commission Sentinel Event Alert1 discusses the need for staff to have opportunities to communicate concerns and get support related to fatigue concerns. The ability of organizations to build strategies (such as double-checks for critical tasks) to support staff who identify fatigue as a concern will also help protect patients from harm. Investigations surrounding adverse events should routinely consider fatigue as a potentially contributing factor. Finally, The Joint Commission recommends that all organizations with a current policy that allows sleep breaks for staff provide a suitable environment that fully protects sleep. The alert goes on to define “fully protected sleep,” stressing uninterrupted coverage of all responsibilities and ensuring an environment that supports sleep.1 Through these recommendations, The Joint Commission is working to acknowledge and address a serious issue, providing great opportunity to improve patient safety outcomes and staff wellness. The workload-staffing imbalance must be addressed. At night, combining the 3 strategies of schedule design, sleep opportunity training of employees, and task engineering for environmental factors will increase alertness. More frequent short breaks of 5 to 15 minutes every 1 to 2 hours have been shown to reduce fatigue.2 Furthermore, work breaks must be allowed on a frequent and regular basis and should be based on the nature of the work. Jobs that are physically and cognitively more demanding may require more time away from the work areas.2 In addition, time away should be scheduled and/or self-selected and be allowed before staff experience fatigue. The potential benefits
328 Copyright © 2014 American Association of Critical-Care Nurses. Unauthorized reproduction of this article is prohibited.
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Creating a Healthy Workplace
of a robust FRMS are invaluable to the safety and well-being of the employee, the cost-benefit advantage of the organization, and the quality of care provided to patients and their families.2 Summary Several overall recommendations are available to help manage fatigue in your work area. Nurses should be accountable for coming to work fit for duty, which includes adequate sleep and minimizing long stretches of work shifts. Administrators should ensure that appropriate scheduling practices are used to maximize alertness among staff. Nurses should be discouraged from additional employment beyond their full-time positions, given the adverse effects of fatigue on patient safety and their own health. Human resource policies should be established that prohibit moonlighting among full-time employees. The Institute of Medicine10 report Keeping Patients Safe calls for fatigue management education for nurses as well as testing methods to reduce fatigue. By implementing policies or guidelines on the basis of these recommendations, organizations can maintain a healthy work environment, which provides for appropriate staffing of well-rested nurses.
REFERENCES 1. The Joint Commission. Health care worker fatigue and patient safety. Sentinel Event Alert. Issue 48, December 14, 2011. http://www.jointcommission.org/assets/1/18/SEA_ 48.pdf. Accessed July 22, 2014. 2. American College of Occupational and Environmental Medicine. Fatigue risk management in the workplace, guidance statement. J Occup Environ Med. 2012;54(2): 231–258. 3. Townsend T, Anderson P. Are extended work hours worth the risk? Am Nurse Today. 2013;8(5):8–11. 4. Hanecke K, Tiedemann S, Nachreiner F, Grzech-Sukalo H. Accident risk as a function of hour at work and time of day as determined from accident data and exposure models for the German working population. Scand J Work Environ Health. 1998;24(suppl 3):43–48. 5. Scott L, Hofmeister N, Rogness N, Rogers A. An interventional approach for patient and nurse safety. Nurs Res. 2010;59(4):250–258. 6. Brown LK. Fatigue is the best pillow: sleepiness vs fatigue in sarcoidosis. Chest. 2013;143(8):1523–1525. 7. Scott L, Arslanian-Engoren C, Engoren M. Association of sleep and fatigue with decision regret among critical care nurses. Am J Crit Care. 2014; 23:13–23. 8. National Association of Neonatal Nurses. NANN position statement: The effect of staff nurses’ shift length and shift on fatigue and patient safety, position statement #3054. http://www.nann.org/uploads/files/The_Effect_of_Staff_ Nurses_Shift_Length_and_Fatigue_on_Patient_Safety_2011.pdf. Accessed July 22, 2014. 9. Association of periOperative Registered Nurses. Position statement on perioperative safe staffing and on-call practices. https://www.aorn.org/PracticeResources/AORNPositionStatements/. Accessed July 22, 2014. 10. Institute of Medicine. Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, DC: National Academies Press; 2004.
329 Copyright © 2014 American Association of Critical-Care Nurses. Unauthorized reproduction of this article is prohibited.
NCI-D-14-00036.indd 329
14/10/14 8:05 PM
Creating a Healthy
Workplace
Nancy Blake, RN, PhD, CCRN, NEA-BC Department Editor
Reducing Worker Fatigue to Create a Healthy Work Environment Nancy Blake, RN, PhD, CCRN, NEA-BC Kay Gilmore, RN, MN Phan Dang, RN, MN Dan Villareal, RRT, MBA
R
ecent research about fatigue in health care has motivated nurses and hospital administrators to look at ways to manage the problem. This column examines a few relatively recent studies and alerts about the problem of fatigue.1–5 Defining Fatigue and Its Implications Ironically, Ben Franklin, founder of our nation’s first hospital, Pennsylvania Hospital, identified fatigue as a common health complaint.6 However, fatigue is one of the most difficult terms to define, and it is a symptom of many different conditions. Fatigue is generally defined as a feeling of lack of energy. It is not the same as sleepiness, but the desire to sleep may accompany fatigue.2 The American College of Occupational and Environmental Medicine’s (ACOEM’s) Task Force on Fatigue Risk Management provided us with an extensive review of fatigue and how we can reduce its risk to provide a balanced, healthy work environment.2 Evidence suggests that shift work associated with extended hours increases the risk for fatigue. Moreover, fatigue risk factors increase the likelihood of apathy, which is common in today’s shift workers, interfering with their productivity and performance.2 However, hours-of-service is not the only contributing factor that must be addressed. We must also consider workers’ time spent sleeping at home and the availability of rest at work. The Joint Commission reviewed the impact of fatigue on health care workers as well as factors that contribute to fatigue and the inherent increased risk to patients, and made important evidence-based recommendations in a Sentinel Event Alert1 published in December 2011. The alert presented clear evidence that nurses who work shifts of 12.5 hours or longer are at greater risk for errors and occupational injuries.1 This alert emphasizes the importance of developing evidence-based practice surrounding the issue of worker fatigue with those working 12.5 hours, hours of sleep, and truly addressing the culture surrounding this issue.
Nancy Blake is Director, Critical Care Services, Children’s Hospital Los Angeles, 25720 Oak Leaf Court, Valencia, CA 91381 ([email protected]). Kay Gilmore is Manager, Cardiovascular Acute Unit, Children’s Hospital Los Angeles, Valencia, California. Phan Dang is Manager, Acute Rehab, Children’s Hospital Los Angeles, Valencia, California. Dan Villareal is Manager, Respiratory Care, Children’s Hospital Los Angeles, Valencia, California. The authors declare no conflicts of interest. DOI: 10.1097/NCI.0000000000000052
326 Copyright © 2014 American Association of Critical-Care Nurses. Unauthorized reproduction of this article is prohibited.
NCI-D-14-00036.indd 326
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V OL UME 2 5 • N U MBER 4 • OCTOBER–DECEM BER 2014
Creating a Healthy Workplace
Extended Work Hours Are extended work hours worth the risk? Industrial research indicates that worker productivity declines after 10 to 12 hours of work. Currently, about 75% of nurses work 12-hour shifts. Fatigue and sleep deprivation are linked to decreased vigilance, memory, information processing, reaction time, and decision making.3 US Army studies show that staying awake for 17 hours is equivalent to a blood alcohol level of 0.05%, and staying awake for 24 hours is equivalent to 0.10%.3 The California legal limit is 0.08%. The American College of Graduate Education restricts resident duty hours to 80 hours per week. Truck drivers are limited to 11 hours behind the wheel.3 The Federal Aviation Administration restricts pilot actual flight time to 16 hours.3 Railroad workers are required to take a 10-hour break before a new shift.3 A German study shows that injuries increase exponentially after the ninth hour of work.4 Work schedules can affect the sleep-wake cycle. Working extended hours can lead to musculoskeletal injuries. Blood-borne pathogen exposure increases during the last 2 hours of a 12-hour shift, and longer shifts increase burnout and job dissatisfaction. Nurses working 10 hours or more are 2½ times more likely to experience burnout.4
National Recommendations Worker alertness is partially dependent on the organization’s ability to develop and implement a Fatigue Risk Management System (FRMS) that will best fit the work environment. Thus, a fatigue risk management plan is essential for a healthy work environment. ACOEM Task Force key recommendations for a robust FRMS include 6 core components.2 See Table 1 for the core components with examples. The process for internal and external auditing of an FRMS can result in corrective actions for the organization through a continuous improvement process aimed at employee safety.2 The more complex the organization, the more robust the quality improvement process needs to be to prevent systems issues. Integration of an FRMS with other safety and health management systems is important. Addressing fatigue addresses safety for both patients and staff. If implemented correctly, a fatigue avoidance
Shift Work and Sleeplessness Scott et al5 found that shift work was associated with higher errors. Long work hours coupled with poor sleep are riskier work conditions (eg, 16-hour shifts returning to work with less than an 8-hour break). Drowsiness is not confined to the night shift. Alarmingly, 63% of the nurses studied described drowsy driving. Multiple errors or near misses were described when nurses stated that they were drowsy. If working over 16-hour shifts, staff nurses were 3 times more likely to make errors.5 In a more recent study by Scott et al,7 critical care nurses described that they were more likely to have clinical decision regret if they have inadequate sleep. When nurses make patient care decisions when they are sleepy, and the outcomes of these decisions are less desirable or unfavorable, negative affective emotions can surface that manifest as decision regrets. These decision regrets are failure to adhere to standard of practice, failure to be a patient advocate, failure to ensure patient safety, impaired cognition, failure to communicate in a professional manner, and negative affective responses.7
Table 1: Core Components of a Fatigue Risk Management System2 With Examples Core Component
Examples
Safety and Management Policy
This could include information on hours worked, structures, policies, practices, and shared responsibilities of staff and management.
Risk Management
Preventing human errors (managing sleep) and systems issues (staffing levels and appropriate amount of light)
Reporting
Attendance, safety and health metrics, the use of possible tools to assess fatigue
Incident Investigation
Assessing details related to fatigue, scheduling, staffing, and environment at the time of incident
Training and Education
Training about fatigue management as a joint responsibility as well as how much sleep the employee should get, and staffing and scheduling practices
Internal and external auditing
Internal auditing of incidents (eg, medication errors) and external auditing by an expert in occupational health
327 Copyright © 2014 American Association of Critical-Care Nurses. Unauthorized reproduction of this article is prohibited.
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Creating a Healthy Workplace
W W W .A A CNA D VA NCE D CRIT ICA LCA RE .COM
program can result in a system to maintain worker alertness. ACOEM also states that managing fatigue is a shared responsibility between the organization and the employee.2 Therefore, the employee plays a critical role. Getting adequate sleep requires attentive planning of work schedules so that “he or she does not start work with 8 or more hours of continuous wakefulness before start of duty.”2(p234) If the employee’s circumstances preclude sufficient sleep for any reason, then the employee has the responsibility to report or notify his or her manager. An organization’s FRMS should have 5 key elements to protect against errors from fatigue, including balance between workload and staffing, appropriate shift scheduling, employee fatigue training and sleep disorder management, workplace management environment design, and fatigue monitoring and alertness for duty. The organization must have a system of determining the effect of staffing and workload levels on the hours the employee is on service. A robust scheduling management system can track an employee’s number of scheduled days and number of hours worked. This system will proactively protect against fatigue.2 The American Nurses Association recently released the first draft of its position statement “Addressing Nurse Fatigue to Promote Safety and Health.” The final recommendations should be released soon, and it is important that hospital administrators and nurses implement the recommendations that come from a committee of experts who have done much of the research on fatigue in hospitals themselves. It is also important for nurses to be aware of the recommendations of their specialty organizations on this topic. The National Association of Neonatal Nurses has a position statement,8 as does the Association of periOperative Registered Nurses,9 which recommends that nurses work no more than 12 hours in a day and no more than 60 hours in a 7-day period. This recommendation addresses the on-call nature of their business.9 Organizational Commitment Among the actions recommended for all organizations is to assess the organization for fatiguerelated risks.1 In addition to reviewing pertinent policies to ensure that fatigue is addressed, organizations need to secure data related to the extent of off-shift hours and consecutive shifts. Also, the high-risk nature of hand-offs
for fatigued workers at the end of shifts of 12.5 hours (or more) must be recognized, and processes and procedures put into place to ensure that patients are protected. Soliciting staff input into the design of work schedules to minimize potential fatigue seems simple, but it is of utmost importance. The creation and implementation of a fatigue management plan not only recognizes the challenges but takes proactive steps to develop strategies for fighting fatigue. This plan, along with staff education about sleep hygiene and the effects of fatigue on patient safety, can benefit all organizations. In addition, building a culture of safety surrounding fatigue is an enormous opportunity for all health care organizations, as many have had “a culture of working long hours and the impact of fatigue has not been a part of our consciousness.”1 The Joint Commission Sentinel Event Alert1 discusses the need for staff to have opportunities to communicate concerns and get support related to fatigue concerns. The ability of organizations to build strategies (such as double-checks for critical tasks) to support staff who identify fatigue as a concern will also help protect patients from harm. Investigations surrounding adverse events should routinely consider fatigue as a potentially contributing factor. Finally, The Joint Commission recommends that all organizations with a current policy that allows sleep breaks for staff provide a suitable environment that fully protects sleep. The alert goes on to define “fully protected sleep,” stressing uninterrupted coverage of all responsibilities and ensuring an environment that supports sleep.1 Through these recommendations, The Joint Commission is working to acknowledge and address a serious issue, providing great opportunity to improve patient safety outcomes and staff wellness. The workload-staffing imbalance must be addressed. At night, combining the 3 strategies of schedule design, sleep opportunity training of employees, and task engineering for environmental factors will increase alertness. More frequent short breaks of 5 to 15 minutes every 1 to 2 hours have been shown to reduce fatigue.2 Furthermore, work breaks must be allowed on a frequent and regular basis and should be based on the nature of the work. Jobs that are physically and cognitively more demanding may require more time away from the work areas.2 In addition, time away should be scheduled and/or self-selected and be allowed before staff experience fatigue. The potential benefits
328 Copyright © 2014 American Association of Critical-Care Nurses. Unauthorized reproduction of this article is prohibited.
NCI-D-14-00036.indd 328
14/10/14 8:05 PM
V OL UME 2 5 • N U MBER 4 • OCTOBER–DECEM BER 2014
Creating a Healthy Workplace
of a robust FRMS are invaluable to the safety and well-being of the employee, the cost-benefit advantage of the organization, and the quality of care provided to patients and their families.2 Summary Several overall recommendations are available to help manage fatigue in your work area. Nurses should be accountable for coming to work fit for duty, which includes adequate sleep and minimizing long stretches of work shifts. Administrators should ensure that appropriate scheduling practices are used to maximize alertness among staff. Nurses should be discouraged from additional employment beyond their full-time positions, given the adverse effects of fatigue on patient safety and their own health. Human resource policies should be established that prohibit moonlighting among full-time employees. The Institute of Medicine10 report Keeping Patients Safe calls for fatigue management education for nurses as well as testing methods to reduce fatigue. By implementing policies or guidelines on the basis of these recommendations, organizations can maintain a healthy work environment, which provides for appropriate staffing of well-rested nurses.
REFERENCES 1. The Joint Commission. Health care worker fatigue and patient safety. Sentinel Event Alert. Issue 48, December 14, 2011. http://www.jointcommission.org/assets/1/18/SEA_ 48.pdf. Accessed July 22, 2014. 2. American College of Occupational and Environmental Medicine. Fatigue risk management in the workplace, guidance statement. J Occup Environ Med. 2012;54(2): 231–258. 3. Townsend T, Anderson P. Are extended work hours worth the risk? Am Nurse Today. 2013;8(5):8–11. 4. Hanecke K, Tiedemann S, Nachreiner F, Grzech-Sukalo H. Accident risk as a function of hour at work and time of day as determined from accident data and exposure models for the German working population. Scand J Work Environ Health. 1998;24(suppl 3):43–48. 5. Scott L, Hofmeister N, Rogness N, Rogers A. An interventional approach for patient and nurse safety. Nurs Res. 2010;59(4):250–258. 6. Brown LK. Fatigue is the best pillow: sleepiness vs fatigue in sarcoidosis. Chest. 2013;143(8):1523–1525. 7. Scott L, Arslanian-Engoren C, Engoren M. Association of sleep and fatigue with decision regret among critical care nurses. Am J Crit Care. 2014; 23:13–23. 8. National Association of Neonatal Nurses. NANN position statement: The effect of staff nurses’ shift length and shift on fatigue and patient safety, position statement #3054. http://www.nann.org/uploads/files/The_Effect_of_Staff_ Nurses_Shift_Length_and_Fatigue_on_Patient_Safety_2011.pdf. Accessed July 22, 2014. 9. Association of periOperative Registered Nurses. Position statement on perioperative safe staffing and on-call practices. https://www.aorn.org/PracticeResources/AORNPositionStatements/. Accessed July 22, 2014. 10. Institute of Medicine. Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, DC: National Academies Press; 2004.
329 Copyright © 2014 American Association of Critical-Care Nurses. Unauthorized reproduction of this article is prohibited.
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