Madison was at the end of her third 12-hour night shift when it happened.  She was giving the morning insulin at 4 am, as she had done so many times in her 3 years at the prison. This time, however, she took a vial from the cart and drew up and administered 20 units of regular insulin to Mr. Sender instead of the NPH ordered. The error wasn’t discovered until after he had passed out while getting his breakfast tray. Thankfully, Mr. Sender recovered with glucagon administration and had no permanent injury, but Madison was devastated by the error and questioned her nursing abilities. The post-incident investigation revealed that there was no NPH on the cart, only two vials of Regular insulin. She did not remember checking the label of the vial she used before administering the insulin, but she remembered that the label of the other vial said “Regular,” so she chose the one she did. She was tired.

Correctional nurses work hard…and long…with many schedules based on 12-hour shifts. Considering the commute time it can take to get to a remote correctional facility and the time and effort to pass through security and various sally ports, longer shifts seem practical. However, research is now indicating that nurse fatigue can have a detrimental effect on patient safety and on the physical and mental health of the nurse.

Research on the effects of nurse fatigue indicates that nurses working more than 12 hours a day are three times more likely to make a patient care error. Additional research into nurse fatigue confirms that long shift length increases error, close calls, and decreased vigilance. This latter finding can have particular application in the correctional setting where nurses must be vigilant, not only for patient safety, but their own safety in a secure setting. A study of shift workers found that risk of accident escalated over time so that the risk of accident was 17% higher on the fourth straight night of shift work.

According to the Joint Commission’s blog about Healthcare Workers in Crisis, the following outcomes have been linked to fatigue:

Strategies to Reduce Nurse Fatigue

• Education: Many nurses are unaware of the degree to which lack of sleep affects performance. We can start by being educated about the issue.
• Sleep Hygiene: Just like our patients, we, too, need to have good sleep habits for our health and for patient safety. Having a regular bedtime, getting at least 7 hours of sleep, and avoiding alcohol or caffeine near bedtime can help.
• Organizational Culture: Organizations can set limits on the number of shifts and hours worked by nursing staff. Nurses can feel pressure to fill empty shifts to assist workmates or meet management expectations. This pressure should be withdrawn and other measures sought to meet staffing needs.
• System Checks: Consider staff fatigue when performing root cause analysis for quality improvement purposes. Implement second check processes for critical tasks to overcome fatigue-related error potential. Many traditional health care settings require a second check on insulin administration like the one in our case study.

Have you noticed an effect on your nursing practice when working long shifts? Share your thoughts in the comments section of this post.