Development and evaluation of a matrix for assessing fatigue-related risk, derived from a national survey of nurses' work patterns.

BACKGROUND: Multiple aspects of nurses' rosters interact to affect the quality of patient care they can provide and their own health, safety and wellbeing. OBJECTIVES: (1) Develop and test a matrix incorporating multiple aspects of rosters and recovery sleep that are individually associated with three fatigue-related outcomes - fatigue-related clinical errors, excessive sleepiness and sleepy driving; and (2) evaluate whether the matrix also predicts nurses' ratings of the effects of rosters on aspects of life outside work. DESIGN: Develop and test the matrix using data from a national survey of nurses' fatigue and work patterns in six hospital-based practice areas with high fatigue risk. METHODS: Survey data included demographics, work patterns (previous 14 days), choice about shifts, and the extent to which work patterns cause problems with social life, home life, personal relationships, and other commitments (rated 1 = not at all to 5 = very much). Matrix variables were selected based on univariate associations with the fatigue-related outcomes, limits in the collective employment contract, and previous research. Each variable was categorised as lower (score 0), significant (score 1), or higher risk (score 2). Logistic multiple regression modelling tested the independent predictive power of matrix scores against models including all the (uncategorised) work pattern and recovery sleep variables with significant univariate associations with each outcome variable. Model fit was measured using Akaike and Bayesian Information Criterion statistics. RESULTS: Data were included from 2358 nurses who averaged at least 30 h/week in the previous fortnight in one of the target practice areas. Final matrix variables were: total hours worked; number of shift extensions >30 min, night shifts; breaks < 9 h; breaks ≥ 24 h; nights with sleep 11pm to 7am; days waking fully rested; and roster change. After controlling for gender, ethnicity, years of nursing experience, and the extent of shift choice, the matrix score was a significant independent predictor of each of the three fatigue-related outcomes, and for all four aspects of life outside work. For all outcome variables, the model including the matrix score was a better fit to the data than the equivalent model including all the (uncategorised) work pattern variables. CONCLUSIONS: A matrix that predicts the likelihood of nurses reporting fatigue-related safety outcomes can be used to compare the impact of rosters both at work and outside work. It can be used for roster design and management, and to guide nurses' choices about the shifts they work.

Fatigue and nurses' work patterns: An online questionnaire survey.

BACKGROUND: Fatigue resulting from shift work and extended hours can compromise patient care and the safety and health of nurses, as well as increasing nursing turnover and health care costs. OBJECTIVES: This research aimed to identify aspects of nurses' work patterns associated with increased risk of reporting fatigue-related outcomes. DESIGN: A national survey of work patterns and fatigue-related outcomes in 6 practice areas expected to have high fatigue risk (child health including neonatology, cardiac care/intensive care, emergency and trauma, in-patient mental health, medical, and surgical nursing). METHODS: The 5-page online questionnaire included questions addressing: demographics, usual work patterns, work in the previous two weeks, choice about shifts, and four fatigue-related outcomes - having a sleep problem for at least 6 months, sleepiness (Epworth Sleepiness Scale), recalling a fatigue-related error in clinical practice in the last 6 months, and feeling close to falling asleep at the wheel in the last 12 months. The target population was all registered and enrolled nurses employed to work in public hospitals at least 30 h/week in one of the 6 practice areas. Participation was voluntary and anonymous. RESULTS: Respondents (n = 3133) were 89.8% women and 8% Maori (indigenous New Zealanders), median age 40 years, range 21-71 years (response rate 42.6%). Nurses were more likely than New Zealand adults in general to report chronic sleep problems (37.73% vs 25.09%, p < 0.0001) and excessive sleepiness (33.75% vs 14.9%, p < 0.0001). Fatigue-related error(s) in the last 6 months were recalled by 30.80% and 64.50% reported having felt sleepy at the wheel in the last 12 months. Logistic regression analyses indicated that fatigue-related outcomes were most consistently associated with shift timing and sleep. Risk increased with more night shifts and decreased with more nights with sleep between 11 p.m. and 7 a.m. and on which nurses had enough sleep to feel fully rested. Risk also increased with roster changes and more shift extensions greater than 30 min and decreased with more choice about shifts. Comparisons between intensive care/cardiac care and in-patient mental health nursing highlight that fatigue has different causes and consequences in different practice areas. CONCLUSIONS: Findings confirm the need for a more comprehensive and adaptable approach to managing fatigue. We advocate an approach that integrates safety management and scientific principles with nursing and management expertise. It should be data-driven, risk-focused, adaptable, and resilient in the face of changes in the services required, the resources available, and the overall goals of the healthcare system.

Surgical Management of Multiple Rib Fractures Reduces the Hospital Length of Stay and the Mortality Rate in Major Trauma Patients: A Comparative Study in a UK Major Trauma Center.

OBJECTIVES: To investigate and assess the effectiveness of surgical fixation of rib fractures in complex traumatic chest injuries compared with traditional nonoperative management. DESIGN: Retrospective observational comparative study. SETTING: Level 1 Major Trauma Centre in North West England. PATIENTS/PARTICIPANTS: A total of 83 patients who were admitted urgently to our hospital after major trauma, between August 2012 and March 2015, and fulfilled the criteria for surgical fixation of their multiple rib fractures. Patients who had concomitant nonsurvivable injuries or did not consent for surgery were excluded. INTERVENTION: Open reduction and internal fixation (ORIF) of multiple rib fractures and flail chest segments versus traditional nonoperative management. MAIN OUTCOME MEASUREMENTS: The primary outcome of interest was the total hospital length of stay (LOS). Secondary outcomes included the incidence of intensive care unit (ICU) admission and the incidence of respiratory complications such as hospital-acquired pneumonia, need for mechanical ventilation, and/or tracheotomy. The mortality rate was also investigated. RESULTS: A total of 83 patients were included, 47 of these in the ORIF group and 36 in the non-ORIF group. The mean hospital LOS for patients in the non-ORIF group was 30.41 days (SD 30.1). This was markedly reduced in the ORIF group to a mean of 14.53 days (SD 11.7), with the difference being statistically significant (P < 0.01). Twenty-eight patients (77.7%) in the nonoperatively managed group required admission to the ICU compared with a significantly lower 48.9% (23 patients) in the ORIF group (P < 0.01). The incidence of respiratory complications was lower in the ORIF group but this difference was not statistically significant. The mortality rate was 2.1% for the group that was treated surgically compared with 13.9% for the conservative group (P < 0.05). CONCLUSIONS: Surgical fixation of multiple displaced rib fractures reduced the total hospital LOS and the overall mortality in our major trauma patients and decreased the incidence of ICU admission. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Nurses as family caregivers - barriers and enablers facing nurses caring for children, parents or both.

AIMS: To examine the dual caregiving and nursing responsibilities of nurses in New Zealand with a view to identifying potential strategies, policies and employment practices that may help to retain nurses with caregiving responsibilities in the workplace. BACKGROUND: As the nursing workforce ages, child-bearing is delayed and older family members are living longer, family caregiving responsibilities are impacting more on the working life of nurses. This may complicate accurate workforce planning assumptions. METHOD: An explorative, descriptive design using interviews and focus groups with 28 registered nurses with family caregiving responsibilities. RESULTS: A depth of (largely hidden) experience was exposed revealing considerable guilt, physical, emotional and financial hardship. Regardless of whether the nurse chose to work or had to for financial reasons, family always came first. CONCLUSIONS: Demographic and societal changes related to caregiving may have profound implications for nursing. Workplace support is essential to ensure that nurses are able to continue to work. IMPLICATIONS FOR NURSING MANAGEMENT: Increased awareness, support, flexibility and specific planning are required to retain nurses with family caregiving responsibilities.

The case for end-user involvement in design of health technologies.

This paper reports a subset of data from a mixed methods project interviewing community nurses and nurse leaders/managers to explore the views, expectations, practice and attitudes of registered nurses working in the community concerning electronic health records and the use of mobile devices. Nurses displayed excellent understanding of privacy and consent concerning electronic patient records and health information technology (e-health). With targeted, individualised education, nurses use e-health and telehealth effectively. However, significant barriers were found regarding duplication of paper and electronic patient notes and multiple logins for different platforms and systems, resulting in forgotten and shared passwords. There was also evidence of some avoidance of essential systems; lack of infrastructure in some settings; inadequate systems for the use of digital cameras (e.g. tracking wound healing); and inability to access patient notes across settings to ensure integrated care. In conclusion, nurses are the largest group of health practitioners in New Zealand and are at the front line of patient care. Nurses need systems designed around their work methods and a good understanding of e-health in order to be able to use it effectively. Greater consultation with nurses is required to ensure the potential of e-health and its use is maximised.

The juxtaposition of ageing and nursing: the challenges and enablers of continuing to work in the latter stages of a nursing career.

AIMS: To identify why some nurses cope well with continuing to work as they age and others struggle. BACKGROUND: There is a need to understand better the challenges older nurses face and how they manage them. DESIGN: Secondary analysis of existing data. METHODS: Data collected in two separate studies were analysed. The first study (2012) was an online, anonymous survey that collected free text (qualitative) and categorical data (n = 3273, 57·6% response rate). The second (2014) was an explorative, descriptive study that collected data through focus groups and interviews (n = 46). Qualitative data from both studies were analysed using David Thomas' () general inductive approach. Research Ethics Committee approval was gained for the 2012 and 2014 studies. RESULTS: Data were categorised in two themes: the challenges of ageing and nursing; and factors that enable nurses to continue to practice. Physical challenges, fatigue, guilt, ageism and demands to complete continuing education were considered challenges. Maintaining personal fitness, self care, flexible working and a strong belief in their ability to contribute to the profession were present in older nurses who continued to practice. CONCLUSION: While older nurses face growing physical and cognitive challenges as they age, they demonstrate strong resilience in the face of these challenges. It is recommended nurses seek support from their workplaces early to address challenges. Organisations must address ageism in the workplace and provide practical interventions such as supporting changes to work hours, shifting nurses to less physical roles and providing career planning to support resilience in older workers.

Integrating technology into practice.

A recent NZNO study has shown patchy use by nurses of electronic devices and files. Nurses need more education and support if e-health is to be integrated successfully into nursing practice.

Nurses aged over 50 and their perceptions of flexible working.

AIM: To explore the experiences and needs of older nurses in relation to flexible working and the barriers and facilitators to implementation within workplaces. BACKGROUND: An ageing nursing workforce and anticipated nursing workforce shortages require effective approaches to workforce retention. METHOD: A mixed method approach (focus group and individual interviews) with nurses aged over 50 (n = 46) combined with analysis of district health board (DHB) flexible working policies. RESULTS: Participants had a good understanding of flexible working and recognised the importance of balancing their own needs with those of their organisation. Participants had legitimate reasons for making requests and became frustrated when turned down. They recommended job sharing, shorter shifts, no night shift and greater recognition of their work to improve retention. There was discrepancy between organisational policy (where this existed) and implementation. CONCLUSION: Organisations should review flexible working policies, ensuring these are understood and implemented at the unit level. Training of nurse managers is recommended. IMPLICATIONS FOR NURSING MANAGEMENT: Nurse managers must recognise the individual needs of nurses, be cognisant of workplace policies regarding flexible working, ensure these are implemented consistently and make the effort to recognise the work of older nurses.

Nursing roles and responsibilities in general practice: three case studies.

INTRODUCTION: Primary care nursing teams may now comprise registered nurses (usually termed practice nurses), nurse practitioners, physician assistants, enrolled nurses, and primary care practice assistants, clinical assistants, or nursing assistants. There is a need to understand how practitioners in the different roles work with patients in the changed environment. The aim of this study was to describe the different configurations of health professionals' skill-mix in three dissimilar primary care practices, their inter- and intra-professional collaboration and communication, and to explore the potential of expanded nursing scopes and roles to improve patient access. METHODS: Document review, observation and interviews with key stakeholders were used to explore how health practitioners in three practice settings work together, including their delegation, substitution, enhancement and innovation in roles and interdisciplinary interactions in providing patient care. A multiphase integrative, qualitative and skill-mix framework analysis was used to compare findings related to nursing skill-mix across case studies. FINDINGS: Three models of primary care provision, utilising different nursing skill-mix and innovations were apparent. These illustrate considerable flexibility and responsiveness to local need and circumstances. CONCLUSION: Enabling nurses to work to the full extent of their scope, along with some adjustments to the models of care, greater multidisciplinary cooperation and coordination could mitigate future workforce shortages and improve patient access to care.

Walking in two worlds.

It has been nearly quarter of a century since nursing educator Irihapeti Ramsden wrote the guidelines on cultural safety (Kawa Whakaruruhau), ratified in 1992 and subsequently much revised (most recently in 2011) by the Nursing Council. The Te Puna Hauora Kaupapa Nursing Service at Tauranga Hospital has been in existence for more than 18 years. Despite this, the experiences of Maori nurses described here, and the lack of adoption of truly bicultural nursing services in other parts of the country, indicate far more investment is needed in Maori nursing. What all those working in the health-care system need is the capacity to deliver whanaungatanga models of care, through cultural awareness education, and through the development of cultural competencies.