Finding Solutions for Stressed Out, Exhausted Nurses, and Potentially Depressed RNs

A new survey of more than 3,300 registered nurses (RNs) shows that a majority were extremely stressed out due to lack of sleep, long hours, and numerous other workplace issues.

These high levels of stress and fatigue could lead to medical errors, and negative patient outcomes, as well as an increase in nurse burnout, further aggravating the current nursing shortage, according to the study by the Vickie Milazzo Institute, a legal nurse consulting training institute.

Among the findings, 64 percent of respondents indicated that they rarely get seven to eight hours of sleep and 33 percent said they hardly ever get that amount. Twelve-hour shifts and on-call shifts after regular shifts and overnight shifts contribute to the fatigue problem, according to the study. Fatigue and irregular sleep patterns can also lead to health problems for nurses, including increased risk of depression and anxiety disorders.

An INQRI-funded study, published in the May/June 2012 issue of the journal Clinical Nurse Specialist, looked at how depression and musculoskeletal pain among nurses impacts workplace productivity and quality of patient care. Researchers found that nurses experience depressive symptoms at a rate twice as high—18 percent—as the general public. The team found that pain and depression were significantly associated with presenteeism, which was significantly associated with patient falls, medication errors, and the perceived quality of care. Additionally, depressed workers often exhibit low mood, have difficulty concentrating, and are accident-prone.

The researchers analyzed surveys from 1,171 hospital nurses in North Carolina and found that the productivity loss due to pain and/or depression was $14,339 per nurse and $876.9 million for the state of North Carolina. If these numbers were extrapolated to the nation, the productivity loss would be $22.7 billion.

Addressing the Problems

According to the Milazzo study, other factors contributing to high levels of stress for RNs are an unhealthy work/life balance, lack of authority, recognition, and fair pay in the workplace, and lack of effective management. To address these issues, the study recommends that hospitals:

• Make work hours for RNs realistic and sane;
• Provide access to nutritious food;
• Allow experienced RNs to have the authority to do their jobs and provide RNs with management opportunities; and
• Improve management style to recognize RN’s unique contributions and provide fair pay, adequate paid time off, and a positive work environment.

As the INQRI study points out, it is also imperative to devote more attention to depression screening and early treatment for nurses. Advanced practice nurses can educate staff RNs about the high prevalence of depression in nurses, who, like the general population, may be reluctant to get screening and treatment, due to the social stigma attached to mental illness. The study identified Web-based screening as a confidential and cost-effective means of reaching the nursing population.

Other strategies for assisting nurses with depression include increasing staff nurses and managers’ awareness of and sensitivity to depression, advocating policies that support good mental health and treatment for those with problems, and promoting supportive work environments, according to the study.

The Effects of Nurse Presenteeism on Quality of Care and Patient Safety was led by INQRI grantees Susan Letvak and Christopher J. Ruhm.

The Vickie Milazzo Institute survey results are available here.

Study of Nurses Shows Benefit of Mindfulness-Based Stress Reduction

The results of a research project that included a group of nurses suggests that implementing a Mindfulness-Based Stress Reduction (MBSR) program could help reduce employee stress and burnout, Medical Xpress reports.

MBSR was first developed in 1979 to teach patients with chronic medical conditions how to lead fuller and healthier lives, according to the researchers. Mindfulness is defined in the research as “a self-directed practice for relaxing the body and calming the mind through focusing on present-moment awareness.”

The MBSR study, led by Dawn Bazarko, senior vice president of the Center for Nursing Advancement at UnitedHealth Group, included 41 female nurses who participated in an eight week scheduled course of guided instruction in mindfulness meditation practices, facilitated group discussion, stretching and yoga, work and home assignments, and individually tailored instruction and support, according to Medical Xpress. 

Researchers surveyed the nurses’ overall health and well-being at three intervals: prior to beginning the program, immediately following the program, and four months after the program was complete. They found statistical improvement in overall health and wellness of the nurses at each of these markers.

While the study was conducted with nurses, it was intended to show that MBSR is a universal practice and can be utilized by a variety of clinical and non-clinical professions. The findings were published in the Journal of Workplace Behavioral Health.

Using Technology to Help Nurses Spend More Time on Direct Patient Care

A study published in 2008 found that medical-surgical nurses spent 19.1 percent of their time involved in patient care activities, but 35.3 percent on documentation. A blog on Advance for Nurses by Michael Wong of the Physician-Patient Alliance for Health & Safety discusses the ways that nurses can use technology to improve patient safety and allow them to spend more time providing direct care.

The blog is based on the recommendations of three nurses who spoke at the Patient, Safety Science & Technology Summit held in January of this year. Those nurses are: Lillee Gelinas, vice president and chief nursing officer of VHA, Inc.; Linda Groah, executive director of the Association of perOperative Registered Nurses; and Juliana Morath, chief quality and safety officer at Vanderbilt University Medical Center.

Their recommendations include: using monitoring technology as a patient safety net; using monitoring technology that incorporates multiple parameters into a single system as opposed to monitoring things separately; and ensuring that technology is nurse-friendly. Wong also recommends that nurses be an integral part of the process of selecting and implementing the use of the technology they will use and interact with.

An INQRI-funded study led by Linda Flynn and Dong-Churl Suh found that nurses were better able to intercept medication errors when they worked in a supportive environment, including opportunities to participate in hospital decisions and continuity of patient care assignments, among other factors.

Health Wonk Review Carnival Now Live

Check out this week's edition of the Health Wonk Review over at the Workers' Comp Insider blog.  Mark Pauly's post from this week is featured in the carnival along with a lot of other great reads.  Take a look. 

INQRI Goes International

INQRI grantee Patti Hamilton recently had the opportunity to present on missed care and off-peak work environments to the Australian Nurse and Midwifery Federation. The findings are the result of a joint study with Midwestern State University and Flinders University. It is an international extension of Dr. Hamilton's INQRI study, "The Effect of Off-peak Hospital Environments on Nurses' Work: an Institutional Ethnography."

The research team interviewed 354 nurses and midwives in Australia using Kalisch's MISSCARE instrument to determine which items of care were commonly missed and to understand why.  Respondents noted a wide range of "missed care" items, including: bathing patients, providing adequate discharge information, handwashing, patient education, and much more.  Perceived reasons for these omissions included: communications challenges, inadequate hand-offs and number of staff, heavy admission and discharge needs, and more.

Similar to the results of Hamilton's original INQRI study with Dr. Gretchen Gemeinhardt, more issues occurred during "off-peak" shifts.

The MSU-Flinders team also found results similar to those identified in another INQRI study, conducted by Dr. Sue Letvak and Christopher Ruhm, "The Effects of Nurse Presenteeism on Quality of Care and Patient Safety." Letvak and Ruhm found that nurse "presenteeism" (nurses working when sick) was significantly associated with patient falls, medication errors and the perceived quality of care.  Hamilton and her colleagues at Flinders found that the number of shifts worked by nurses who were sick or fatigued related to the total number of missed care items reported.

Congratulations to Dr. Hamilton and her colleagues, Eileen Willis (principal investigator), Julie Henderson, Claire Verrall, Clare Harvey, Liz Abery, Luisa Toffoli, and Ian Blackman on this important work!

INQRI in the News

Check out some recent news coverage of INQRI projects...

Last week, we told you about a new journal article authored by INQRI grantees who found that a combination of strategies and practices can reduce deadly hospital acquired infections.  These findings were the topic of two new articles:

• "Proven Strategies Reduce Deadly Hospital-Acquired Infections," HealthCanal.com
• "Proven strategies successful in reduction of deadly hospital-acquired infections," MedicalXpress.com

An INQRI journal article published in August continues to receive press.  This project found that better work environments for nurses led to fewer medication errors.  It was recently covered on three more sites:

• "Study: Supportive Nursing Environment Linked to Reduced Medication Errors," Becker's Hospital Review.com
• "Medication Errors," OncLive.com
• "Nurses’ interception practices reduce costly errors," Nurse.com

INQRI Project on Reducing Medication Errors

At the end of August, we shared that the findings from an INQRI project showing that better environments for nurses contributed to fewer medication errors were published in the Journal of Nursing Scholarship.

Since that time, the study has continued to garner interest in the press.  Check out some of the latest stories:

• "Better Nursing Environments Reduce Medication Errors," NurseZone.com

• "Nurses Catch More Medication Mistakes in Supportive Hospitals," FierceHealthcare.com
  
  

The Importance of Wellness In the Workplace

For those of you who follow the INQRI blog, you may be familiar with our coverage of issues addressing the health of the nursing workforce. Earlier this summer, a group of health care, human service, and education providers in Northeast Ohio created an innovative nursing initiative, which is currently undergoing rigorous external evaluation, to support health, satisfaction and the quality of care delivered by front-line nurses. Pamela A. Maidens, MA, CPM wrote a fantastic summary of how this initiative came about, why it is important, in addition to describing how the educational program works.

To read more about this wellness initiative, click here.

Nurses Utilize Training and Education Outside of Health Care Sector

With nursing shortages being reported nationwide and new nurse graduates having difficulty finding clinical positions, nurses are now turning to other industry to utilize their training and education in the workplace. Lyn Dowling, reporting for Florida Today, detailed how nurses are being entrepreneurs as consultants, trainers, risk auditors, etc. outside of the health care sector.

To read more about nurses working outside of health care, click here.

Nurses' Adverse Work Schedules Linked to Obesity

A recently published study in the Journal of Occupational and Environmental Medicine found that nurses who work long hours, have a high work burden, are required to be on-call/ utilize overtime, and/or lack of rest are more prone to risk factors associated with obesity. The research team associated 'adverse work schedules' with less restful sleep, and less exercise, thus increasing the likilihood of obesity among nurses working these type of schedules.

To read more about the research, click here.

To read the research publication, click here (subscription required).

How to Better Motivate Nurses and Cut Costs

Yesterday, Karen Minich-Pourshadi, Senior Editor for HealthLeaders Media, published a fascinating piece that discussed innovative ways for hospital systems to cut costs while motivating their nursing workforce. Ms. Minich-Pourshadi recommends that hospitals take a cue from airline companies and utilize a point system, similar to 'travel miles', that rewards nurses for covering their colleagues shifts or providing exemplary care. The case study presented by Ms. Minich-Pourshadi demonstrates how hospitals are looking at other industries to solve some of their workforce issues that previously was viewed as unfeasible.

To read more about this innovative program, click here.

60th National Student Nurses Association Convention's Keynote Speech Focused on Closing the Nurse Safety Gap

Last week, the National Student Nurses Association (NSNA) convened for their 60th anniversary conference in Pittsburgh, PA. Mary Foley, PhD, RN, director at the Center for Nursing Research and Innovation at the University of California San Francisco School of Nursing and a past American Nurses Association president, served as the keynote speaker and addressed the issue of nurse safety to the many future and currnet nurses in attendance. While nurse safety has always been an issue in the health care sector, Dr. Foley told the attendees that there is little work actually being accomplished on the ground for nurse safety to improve. Dr. Foley also promoted her work with the safety group, Safe in Common, which just launched a new Needlestick Safety Advocacy national tour and education campaign.

Click here to read HealthLeadersMedia coverage of the conference, which also includes a short interview with Dr. Foley (on pages 2 & 3).

New Nursing Graduates Cost More to Hire, May Struggle to Find Jobs

Yesterday, Fantasi Pridgon, reporting for The Rebel Bell (a student run newspaper at the University of Nevada, Las Vegas), cited the latest Nevada Health Care Quality Report that indicated that new nursing graduates are having difficult finding positions in acute care facilities. This is a result of the time and effort acute care facilities must invest in new nursing graduates as they take time to acclimate to a new working environment. In a time where hospitals are having numerous budgetary issues, this report does not bode well for new nursing graduates who are seeking employment in this specific sector of health care.

What are your thoughts or experiences with new nursing graduates at your workplace?

Click here to read the full article.

Men Shoring Up Nursing Shortage in Female Dominated Career

Following up on previous posts (covered here and here), Barry Carpenter, of CW33 in Dallas, TX, discussed how a greater number of men then ever are now entering the nursing workforce as their second career. Mr. Carpenter emphasized how men initially trained in the business, accounting or physical labor field are now looking toward the nursing sector for job security and a position that benefits them both financially and personally.

Click here to read the full article.

Nursing Practices Reduce Errors

We are pleased to share with you a recent news article, written by Stephanie Bouchard, Associate Editor for healthcarefinancenews.com, that gave an overview of a recently funded INQRI study. The article highlights a study conducted by Dr. Linda Flynn and her colleagues at Rutgers University that focuses on identifying nursing care practices and work environment management practices used by nurses on medical-surgical units that prevent medication errors and improve patient safety.

Click here to read the full article.

Click here to read other blogposts discussing the work of INQRI grantees.

Study: Nurse Safety, Patient Safety Linked

While we have previously dedicated numerous blogposts to this issue, we feel as though new studies that provide further insight into the topic of nurse and patient safety should continue to be shared.

Yesterday, UPI.com detailed a recently published study that found that a safe working environment for nurses is also a safe environment for the patients in their care. The study, which can be found in the October edition of the BMJ Quality and Safety, was conducted by Dr. Jennifer Taylor of the Drexel University School of Public Health.

Click here to read the news article.

Click here to read the journal article (subscription required).

Click here to read other blogposts relating to nurses' work environment and patient safety.

Morehead Hosts Live Webcast on Creating a High-Performing RN Workforce

Next Tuesday, Morehead Associates, Inc., will host a free, hour-long webcast on creating an efficient and effective RN workforce by attracting high-performing nurses from outside organizations or building an engaged workforce from within. The webinar is intended to identify the organizational factors associated with a high-performance environment, as well as give participants a better understanding of the impact a high-performance environment can have on nurse engagement and retention.

Click here to find out more information on the webinar.

Q&A With Previous INQRI Grantee, Mary Blegen

Diana Austin of Healthcanal.com, published an interview with previous INQRI grantee, Mary Blegen, RN, PhD, FAAN. In this interview, Dr. Blegan, who currently is the Director of the Center for Patient Safety in the UCSF School of Nursing, discusses the importance of interdisciplinary teamwork in improving patient safety in the nation's hospitals.
Click here to read the full interview with Dr. Mary Blegan.

To read more about Dr. Blegan's research team and other INQRI grantees' study results regarding nurse staffing and environment, click here.

Nights and Weekends... Dangerous Times to be in the Hospital

In a new Washington Post article, writer Sandra Boodman discusses a series of studies which all demonstrate that being in the hospital at night or over the weekend can be "hazardous to your health."

INQRI researchers at Midwestern State University agree with that assessment. Led by Patti Hamilton and Gretchen Gemeinhardt, the team learned how and why off-peak work environments are different from those of peak times and how they affected nurses' work and patient care.

Click here to view a presentation of the Hamilton-Gemeinhardt team's findings.

Click here to read the Washington Post article.

Guest Blogger: INQRI Grantee Susan Letvak

As the Initiative on the Future of Nursing report illustrates, nurses:

• Are the largest component of the health care workforce;
• Spend the most time with patients; and
• Understand care processes across the continuum of care.

Evidence, like the findings generated by the INQRI program, links nurses to high-quality patient care. I commend the committee on their work in understanding the important role of nurses and making such compelling recommendations for ensuring that nurses’ voices are heard and their skills put to the greatest possible use.

 

To that end, it is vitally important that we give nurses the resources they need to be able to deliver the quality of care that our country expects and deserves while also helping to cut costs. The report talks much about developing leadership opportunities and supporting lifelong learning endeavors to allow nurses to continue to grow in their roles. I agree that these efforts are incredibly important. However, my research shows that an even more basic need must be addressed to support these vital caregivers. We have to guarantee that nurses are not only a well-trained workforce, but a healthy one as well.

 

High levels of workplace stress, and the physical nature of nursing, have led nurses to experience high rates of musculoskeletal pain and depression. Our recent Robert Wood Johnson Foundation INQRI study found that almost 3 of 4 hospital employed nurses work with some degree of pain and 18% have depression. Most concerning, these health problems have led to a loss of job productivity and a decrease in quality of care (specifically more medication errors and patients falls and a decrease in self perceived ability to provide quality of care). Focus groups with nurses demonstrated that little is currently being done to address the individual health concerns of the nursing workforce. The current economic downturn is presenting even higher job demands on staff nurses who have health problems and those who are being required to “pick up the slack.”

 

In this era of health reform, patients in the U.S. will be looking more and more to nurses to deliver their care. We have to support nurses to allow them to be at their best when they care for patients. This will ensure that care to be of the highest quality at a reasonable cost.

 

Susan Letvak, PhD, RN, is an Associate Professor in the Community Practice Department at the University of North Carolina – Greensboro’s School of Nursing. She recently completed her INQRI-funded project, “The Effects of Nurse Presenteeism on Quality of Care and Patient Safety.”