Celebrate Nurses Week by not overworking them

http://www.progressive.org/national-nurses-week

By Suzanne Gordon, May 6, 2013

National Nurses Week is from May 6 to May 12, and we should honor the work that nurses do, and insist that they get their long hours reduced.

The hours worked by registered nurses (RNs) – the largestt profession in health care – have actually increased over the past several decades.

The average hospital nurse now works a 12-hour shift. Studies on nursing hours have documented that most nurses do not leave after 12 hours but actually work 13 or 14 hours. (In some hospitals, nurses are required to work mandatory overtime, which could mean another eight to 12 hours at work.) When combined with commute times, nurses may be spending 16 or even 17 hours at work and getting to work. This significantly limits the time they have to rest between shifts.

To make matters worse, there are no regulations limiting the amount of back-to-back 12-plus-hour shifts a RN works. As a result, many RNs suffer from chronic sleep deprivation.

Nursing unions have been adamant that banning mandatory overtime is critical, since working extra hours is unsafe to both nurses and patients. The Massachusetts NursesAssociation, for instance, has successfully lobbied for legislation banning mandatory overtime in the Commonwealth.

But bans on mandatory overtime, while certainly necessary, do not address the safety issues inherent in 12-plus-hour shifts. Errors that lead to patient harm increase after eight hours and rise dramatically after 12 hours, particularly when a nurse suffers from chronic sleep deprivation.

Plus, the harm to nurses themselves is significant. Fatigue increases the chance of a needlestick injury, makes concentration on complex tasks more difficult, and creates the kind of irritability that makes it hard for RNs to be empathic or function effectively. What’s more, numerous nurses suffer from injuries sustained
while driving home when fatigued.

Ideally, nurses should go back to the eight-hour shift that so many working people fought for over the last 150 years. Until that happens, 12-hour shifts should be banned at least for those working in critical care area – intensive care units, emergency rooms, and laabor and delivery.

Similarly, working more than three back-to-back 12-hour shifts should not be permitted.

Airline pilots aren’t allowed to fly for more than eight hours, and truck drivers aren’t allowed to drive for more than 11. Both professions have minimum rest periods between their shifts.

So how can we countenance 12-plus hour shifts for the RNs upon whose skill, alertness and judgment so many patients’ lives depend?

(Journalist Suzanne Gordon’s latest book health care or nursing is Beyond the Checklist: What Else Health Care Can Learn from Aviation Teamwork and Safety published by Cornell University Press. She is co-editor of the Culture and Politics of Health Care Work Series at Cornell University Press and can be reached at Lsupport@comcast.net)

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Time to pull the plug on 12-hour nursing shifts

Bostonglobe.com

When the voluntary abandonment of the opportunity to sleep is compounded with overtime things become even more complicated for nurses and patients. Sleep studies document that errors go up. Nurse researcher Ann Rogers has reported that “risks of making an error were significantly increased when work shifts were longer than twelve hours, when nurses worked overtime, or when they worked more than forty hours per week.” But the impact of lack of sleep isn’t only on patients. It’s on nurses themselves.

Nurses who work such long hours have more back, neck and shoulder injuries, suffer from more depression and are also at risk for other health problems. A 2007 study has documented that lack of adequate sleep puts people at twice the risk for cardiovascular problems and early death.

And now we have this new study that tells us that people who don’t get enough sleep suffer from greater brain aging. If you don’t get your seven or eight hours, you can suffer as much as a four to seven year increase in age. Even before this study came out, Geiger Brown and her colleagues asked the question, “Is It Time to Pull the Plug on 12-Hour Shifts?”

My recommendation? Before the month is over, nurses should take a visit to an exhibit at the American Textile History Museum in Lowell, Massachusetts. The museum is a monument to American fabrics and to the workers whose sometimes backbreaking labor produced them. One glass case exhibits a letter written to a mill official in 1867 and signed by dozens of mill workers. It reads as follows:

To the treasurer of the Appleton Corporation. We, the undersigned operatives in your employ, believing that 11 hours a day is inimical to our best moral & physical interests, would most earnestly request you to reduce the term of labor from 11 to 10 hours per day & your petitioners as in duty bound will ever pray.”

When you read this and combine it with all the documentary evidence, the answer to Geiger-Brown’s question — “Is It Time to Pull the Plug on 12-Hour Shifts?” — ought to be an enthusiastic “yes.”

Suzanne Gordon is editor of the Culture and Politics of Health Care Work series at Cornell University Press and co-editor of a forthcoming book on patient safety.

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Walk into a hospital in the United Kingdom, Ireland, the Netherlands and much of Scandanavia and take a good look around. What don’t you see? No male physicians wear ties. No one is wearing a lab coat. No one — male or female — is wearing rings, not even a lone wedding band. No watches adorn wrists – people pull them out of their pockets when they want to check vital signs. No stethoscopes dangle around the neck of either doctors or nurses. There is instead a stethoscope in each patient’s room.

Now consider the United States or Canada. White coats remain the symbol of status for physicians and some elite nurses, like nurse practitioners. Women and men wear rings galore, and it’s hard to find anyone without a wrist watch. Ties — mostly traditional long ones — are de rigeur for docs. And stethoscopes are draped casually around the neck as if the latest fashion accessory.

Why the difference in medical equipment and attire? Health systems in the UK and Europe have acted on studies that document the fact that pieces of standard medical equipment and attire pose the risk of harboring and transmitting a host of dangerous organisms to patients. Ties can dangle into wounds as a doctor is examining a patient; it isn’t therefore surprising that ties have been shown to be colonized with hospital superbugs. Rings can shelter untold dangerous organisms underneath the band, inside an intricate setting, or even in the tiny spaces etched out by a loving inscription. It is impossible to keep many germ free, even if medical staff members take off their rings and washed them everytime they cleaned their hands. Watches and bracelets carry the same infection control hazards. As for stethoscopes, it should come as no surprise that these can be laden with lethal organisms yet are rarely cleaned between patients.

As for lab coats, their long sleeves are constantly touching patients and transporting germs from one to another. They are never changed or washed between patients and rarely laundered everyday, as are hospital scrubs. With scrubs, which leave the arm below the elbow bare, it’s much easier to clean the entire arm that might have inadvertently brushed a patient, a bedsheet, or an open wound.

While numerous studies have documented these dangers, many in healthcare will argue that with the exception of artificial nails, there is no smoking gun that directly links pathogens on a ring, tie, watch etc. with a bad patient outcome. In a culture that worships randomized controlled trials, lack of such “grade A” evidence allows the system to maintain the status quo until further research comes along. One can only imagine how long it will take to run study where patients are rubbed with a contaminated tie or lab coat versus a placebo…

That’s why the Europeans have acted on available evidence rather than wait for the impossible to happen. For them, removing such obvious sources of possible contamination is just common sense much like wearing a helmet while snowboarding. In the United States and Canada, despite more than a decade of intense concern about patient safety and the increasing number of hospital borne infections and “superbugs” there has been little serious action taken on the tie/ring/lab coat etc front. In fact, many prominent patient safety advocates seem to dismiss these things with a kind of “what can we do about it?” shrug. Inactivity speaks volumes: are we really serious about these issues or are people more wedded to the trappings of status and power, or fashion, which not only provide infection risks to patients but also perpetuate the kind of silos and hierarchies that are rife in modern medicine and that are also risks to patient safety. On a recent trip to Sweden where doctors wore short sleeve scrubs and had forgone jewelry, they looked and acted like they were part of the team. Doing away with these medical accessories costs little or nothing. Plus it may help health professionals act their way into a new way of thinking about patient safety.

Suzanne Gordon’s latest book is “Beyond the Checklist: What Else Health Care Can Learn from Aviation Safety and Teamwork.” Dr. Michael Gardam is medical director of Infection Prevention and Control at University Health Network and Women’s College Hospital in Toronto.

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The School has long been doing wonderful work and continues to pioneer in patient safety and in assuring that patients receive the highest quality care from the highest quality practitioners.

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Well, Patrick Mendenhall and I just had an experience, which shows how well strangers can create teamwork in a short of amount of time, if they have a good team leader and have rehearsed it in other settings.

On Wednesday April 24^th, Patrick and I were guests on the Leonard Lopate show, on WNYC/NPR radio talking about our book Beyond the Checklist: What Else Health Care Can Learn from Aviation Teamwork and Safety .  Leonard Lopate has been a radio interviewer for 28 years and Patrick and I have had a lot of experience working with teamwork.  As I sat in Leonard Lopate’s New York City Studio, Patrick was patched in from Tacoma, Washington and was thus a disembodied voice coming over the airwaves.

All of us were virtual strangers. We  had exactly 40 minutes together and it could have gone very badly.   But we had a skilled team leader – Leonard Lopate – who made sure to give us crucial information that enhanced the performance.  Before we went on air,  in just a few moments of small talk with me, Lopate set the tone.  The small talk functioned to make me feel comfortable.  Even though I have done hundreds of radio interviews, it was really helpful.

Once we were on air, it became more difficult to navigate with one person in the room and one coming through the headset.  Patrick couldn’t see either me or Leonard Lopate, and couldn’t read the visual cues that I had as I watched the interviewer in front of me.  It was clear when Leonard Lopate wanted to ask another question or move on.  To me, but not to Patrick.

At one of the breaks, Lopate said, “Listen Suzanne, if you want to ask Patrick something or feel he might have something to add, don’t hesitate.  Feel free to interrupt.  I am not a control freak.”

That was a liberating moment.  Leonard Lopate was the captain of this particular ship. It would have been uncomfortable for me to interrupt him and suggest that Patrick might want to speak to a particular issue. What he did was turn us all into a quick team.  He didn’t just listen, he solicited input.   Not only by asking questions but by giving me permission to invite my colleague sitting across the country to make a comment.

Being a good team leader didn’t mean that Lopate wasn’t a tough interviewer who threw us softballs (he is known, after all, for his astute questioning).  What he exhibited was what we call Team Intelligence (TI).

Lopate had a very short amount of time with us.  A big radio star, he could have arrogantly put us in our place and kept us there.  Instead, he exhibited what the airlines industry calls “mature authority.”  He used everyone’s expertise and was thus able to touch on many relevant issues and raise controversial questions in a short amount of time.  Of course, no one’s life depended on the outcome of a radio show.  But there are lessons to be learned here, and those in healthcare should take note.

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What do I mean by this?  Here’s a typical story.  It began as we lined up at the by now well-known Southwest boarding markers.  I was positioned at A51. As people lined up forward and aft, they began to talk to one another.  First about what number they were – which meant allowing someone to scrunch in in front of or behind you with good grace. Then it involved helping some passenger – in this case an older woman who was unfamiliar with the system and seemed to have a hard time mastering the concept that she was B 50 not A 50 – navigate the procedure.  Schooled by other airlines where you just all jam in, she seemed to find it hard to believe that she couldn’t just scoot in with us A’s.  Politeness was the name of the game here, but so was firmness.

As we were standing in our line, most of us were watching the CNN broadcast in which multiple news casters were relentlessly keeping us up to date on the search for the two men – at that point no one quite knew who they were – thought responsible for bombing the Boston Marathon.  As the young men’s blurred faces appeared on the screen, two men standing behind me were talking about what should be done with them.  One of them blithely insisted that the FBI should just shoot them point blank and claim the suspect was “resisting arrest.” A few minutes later, the a reporter announced that a young college student wearing a white baseball cap had been surrounded by police who thought he was the bomber.  Turned out, he was just a kid wearing a white baseball cap. I wanted to ask my fthe men if they thought the cops should have shot him – he probably would have resisted arrest since he had been guilty of only wearing a white baseball cap.  But in the spirit of Southwest I decided to go for good Karma and keep my mouth shut.

When we walked down the jetway, we were greeted by the two pilots – first officer and captain – who stood outside the planes entrance to say hi.  The older captain didn’t seem to be very chatty, although he smiled pleasantly.  But the first officer was amiable and loquacious, greeting each of us.  “Are you on your way home?” he asked me.  To which I responded yes and asked him if he was too, to which he replied,” Yes, it’s always great to get back.”  The whole interchange couldn’t have taken more than 30 seconds, but you felt in good hands, with people who at least knew that there were human beings in the back of the aircraft – human beings who’d entrusted their lives to the crew’s skills.  When we had boarded and the purser made his safety announcement, he informed us that this was a “no smoking, no whining, and no complaining flight.”  This is not unusual with Southwest, but after a few minutes I realized that it did more than make the passengers feel at ease.  It turned us into a sort of quick team.  How?  After hearing his quip, many passengers, including me and the stranger sitting next to me, turned to one another to smile and say how much we appreciated the airline’s standard operating procedure. (SOP) We then began a conversation that lasted for the next hour.  It made the flight go quicker.  I am sure that we would never have begun to chat had the purser not made his joke.

Later on, when I went back to the aft galley to use the restroom, another passenger was doing some stretching exercises.  The flight attendant was continuing her work without comment.  Then I began doing some stretches and she quipped about the yoga class going on in the galley and said she was tempted to join in.  When another one of the flight attendants joined her, they both began to wonder how many people we could recruit to do yoga in such a small space.  There were no glowering looks from the flight attendants about crowding the galley and no dire warnings of federal marshalls closing down the exercise session.  (I once flew on American to Paris – no pun intended – with my husband in economy and me in business.  I would occasionally walk across the class divide to bring him a goody from my meal.  After a couple of trips back and forth a grumpy flight attendant approached me and told me that there were six air marshalls on the aircraft and that they thought my behavior was erratic and didn’t I know I couldn’t breach economy from business.  No actually I didn’t.  I thought it was the other way around, you couldn’t go from economy to business not vica versa.  I had visions of being knocked to the ground by a bunch of burly guys and taken off to Guantanomo for questioning).

I have always found the crews on Southwest to be genuinely friendly and sympatico.  The company, which is by the way, entirely unionized, has excellent labor management relations and you feel like people actually like to work there.  This rubs off on the passengers, not only in their relationship to the crew but to each other.  Southwest is in a communicating, teamwork mode and you, as a passenger, feel that you are part of the team.

Why don’t health care executives and managers get that they can learn lessons from aviation companies like this?  Many hospitals hire expensive consultants like the Studder Group who force employees to smile at patients and ask of them “is there anything I can do for you, I have time?”  This in spite of the fact that staff workload is so intense that these queries are only pro forma and that the smiles conceal the heartache and frustration of stressed out workers who would love to really have the time to help their patients but actually don’t.  Perhaps for safety’s sake and in their elusive search for customer/patient satisfaction, health care executives should look at yet another lesson of the aviation safety model and consider how at least one airline company puts it into daily practice.  If you treat people well, control the latent pathogens in their work environment, and connect worker health and safety with passenger/patient safety and satisfaction, maybe you can solve problems instead of simply creating new ones.

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But back to this case.

Clearly the institution in question needs to reassess not only its policies but its practices.  Clean stickers need to be taken off once a piece of equipment is in use.  People need to learn to do that.  Anything in a dirty utility room needs to be considered dirty no matter what its sticker says.  If that means spending the money to re-clean something that’s already clean, so be it.  If we cannot afford to spend money on safety, then patients will continue to suffer and die unnecessarily.   I am sure human factors engineers like Kim Vicente or patient safety experts like Lucian Leape  would have even more to say about this.  My take home message is that we have to stop blaming people and start figuring out how to be institutionally and culturally mindful about safety.

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HROs also “worry a lot about the temptation to normalize unexpected events” and thus respect “feelings of surprise.“  People who work in HROs are, as they describe it “mindful.”  “By mindfulness we mean the combination of ongoing scrutiny of existing expectations, continuous refinement and differentiation of expectations based on newer experiences, willingness and capability to invent new expectations that make sense of unprecedented events, a more nuanced appreciation of context and ways to deal with it, and identification of new dimensions of context that improve foresight and current functioning.”  HROs always pay attention to human factors, which as Kim Vicente explains in his book The Human Factor, are  the “problems arising out of the relationship between people and technology, not just at the level of the individual but also at the organizational and even political level.”

As we have argued in our book Beyond the Checklist: What Else Health Care Can Learn from Aviation Safety and Teamwork, aviation shares all the characteristics  of an HRO outlined above.  Because of three decades of mindfulness about safety, aviation, once a very high risk industry, is now a high reliability one.  The other day, my co-author Patrick Mendenhall and I were talking to two former aircraft accident investigators  Douglas Dotan and Ron Schleede .  Both were at work several decades ago as the aviation safety model (ASM) of Crew Resource Management (CRM) was, no pun intended, just getting off the ground.  They had first hand experience of investigating some terrible airline crashes. 

Today’s airline accident investigators, they told us, don’t have the wealth of information they had.  Why not?  Because the ASM has been so successful that there just aren’t that many accidents to investigate.  To Patrick and I, that unarguable statement tells us why health care should learn from aviation safety.  In health care, the same accidents just keep occurring year after year, decade after decade. Because health care leaders have not cultivated and encouraged the kind of mindfulness about safety – both individually and institutionally – that there is in an HRO like aviation.

The following story illustrates the problem.

About two days before we talked to the former aircraft accident investigators, we talked with a friend whom we’ll call Carolyn, who is an experienced nurse on an orthopedic unit at a major US teaching hospital. She had just come off her shift and was disturbed by an experience she had while at work.  During her  shift, a float nurse (an RN who is not attached to a particular unit but who is assigned or “floated” to that unit to fill staff shortages) whom we’ll call Pat, asked our friend where to find an IV pump.  Carolyn told her that they don’t keep usually keep clean pumps on the unit and instead call down to Material Services to get a pump.  At this point another nurse, we’ll call her Joan, jumped into the conversation and told Pat, the float nurse, that she could find an IV pump in the dirty utility room.  Quite alarmed at this idea, Carolyn warned,” if you take an IV pump from the dirty utility room, then you’ll have to carefully disinfect it and it might just be easier for me to call down and get you one that’s already clean.”

Joan, then said, ”No, just take one with the clean sticker on it from the dirty utility room.  They have them in there.”

Carolyn, was even more alarmed at this.  “Well, you can’t assume that an IV pump with a clean sticker is still clean and hasn’t been used if it’s in the dirty utility room.”  It turns out this is precisely what Joan had assumed.  It seems that there is a well developed process to indicate that reusable equipment –I V pumps, monitors, the pump like devices put on patients’ legs to make sure they do not develop a blood clot etc — are clean.  Once they are properly cleaned (which means not just neat and tidy but disinfected) the cleaners put on a colored sticker that says clean and that is dated and initialed by whoever cleaned the equipment.  Problem is there is not a clear process – or at least not one that is clearly understood — about taking those stickers off once equipment is in use.

This is what Carolyn suddenly realized.  Anyone, could put an IV pump with a clean sticker on it into the dirty utility room.  It could be put there because it had been used and needed to be cleaned but no one had taken the sticker off.  It could really be clean – because it had been in a patient’s room but had for some reason not be put to use – and someone like a nursing assistant had stowed it away in the dirty utility room.  It could have been left in a hallway  — either clean or dirty –and put in the room by a housekeeper.  Any number of people – and variables — could have conspired to create this kind of confusion.  But the confusion really stemmed from the fact that there was no agreed upon process that everyone understood about what happens to stickers on reusable equipment once it is used.

Carolyn could not tell us whether or not there was a written policy on the removal of these clean stickers.  There might be some piece of paper somewhere outlining this process.  Or maybe something was sent out to staff.  What she did know was that no one had ever explicityly talked to her about removing the stickers.  Joan told Carolyn she had no idea she was supposed to remove these clean stickers once equipment was in use.

Carolyn, who is very mindful about safety, said she always removes clean stickers on equipment when she sees them. But not everyone does, as this story reveals.  What this means is that people who are very well intentioned and otherwise serious about safety could inadvertently grab a dirty IV pump and think it’s actually clean even though it’s in the dirty utility room because it has a clean sticker on it.  So the clean sticker could trump other information — like the place where the equipment is located – which is for things dirty.

When I recounted this incident to Patrick the next day, the first thing he said was, “You mean they don’t take the clean sticker off immediately when the equipment isn’t put in use?  That’s not on the checklist?”  This, of course,  because of Patrick’s 30 years of experience in an industry that has become mindful of safety.

No, I answered, that’s they problem they don’t.  And by the way there is no checklist, or process, or protocol. Or if there is one it is apparently so invisible that people don’t know about it.   The fact that such a policy might be written on some piece of paper in this hospital is essentially meaningless if people are unaware of the policy or ignore it.

Reading this story someone might be tempted to blame the nurses or aides or whoever puts something clean in a dirty utility room, or someone who would take something that says it’s clean out of a dirty utility room.  That would be to misunderstand both the problem and why we relate the story.  What is important about this incident is that it reveals a lack of mindfulness about safety and the human factor not only in this institution but in so many others. Some nurses, like our friend, take the stickers off.  Others don’t. So a patient’s fate is entirely dependent on the luck of who is in the room, and what their individual attitude/mindfulness is toward infection control and safety.

This is a larger system problem – one that indicates a lack of institutional, not just individual, mindfulness.  If the process for putting on clean stickers was designed with the putting the sticker on in mind as the end point but without considering the how the stickers will be removed so people know something once clean is now dirty, this is a design flaw that needs to be immediately rectified.  If those who designed the sticker process did design a process through which they should be taken off but no one knows about it and it is not routinely referenced, re-referenced and cross-monitored this is also a design problem – a system problem.  Which in turn leads to questions about leadership and management of safety issues within the institution.

It is worth restating that this is a real problem, not just in this hospital, but in many, many others.  Go to any hospital, ask any front line worker and they will identify problems like this that point to an epidemic lack of mindfulness and awareness of the importance of human factors in health care.  This may explain why, in a recent study of nurses in the US, the UK, and China, 41 percent of those surveyed said their hospitals were unsafe.  Ninety four percent of the nurses surveyed said their hospitals have programs in place to promote patient safety, but only 57 percent said they believe the patient safety programs in their hospital were effective.

Both this story and survey point to another reason hospitals need to learn from the ASM.

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