Fatigue in hospital nurses — ‘Supernurse’ culture is a barrier to addressing problems: A qualitative interview study

Abstract

Background

Fatigue in hospital nurses is associated with decreased nurse satisfaction, increased turnover and negative patient outcomes. Addressing fatigue in nurses has been identified as a priority by many organizations worldwide in an effort to promote both a culture of patient safety and a healthy nursing workforce.

Objectives

The overall aim of this study was to explore barriers and facilitators within the hospital nurse work system to nurse coping and fatigue. The purpose of this paper is to describe emergent themes that offer new insight describing the relationships among nurse perceptions of fatigue, nursing professional culture, and implications for the nursing workforce.

Design

A qualitative exploratory study was used to explore nurse identified sources, barriers to addressing, and consequences of fatigue. Participants and setting: Twenty-two nurses working in intensive care and medical-surgical units within a large academic medical center in the United States participated in the interviews.

Method

Interviews with the participants followed a semi-structured interview guide that included questions eliciting participants' views on nurse fatigue levels, consequences of fatigue, and barriers to addressing fatigue. The interview transcripts were analyzed using directed content analysis guided by the Systems Engineering Initiative for Patient Safety (SEIPS) model. Additional themes that did not directly align with the SEIPS model were also identified.

Results

All nurses in the current study experienced fatigue; yet they had varying perspectives on the importance of addressing fatigue in relation to other health systems challenges. A new construct related to nursing professional culture was identified and defined as “Supernurse”. Identified subthemes of Supernurse include: extraordinary powers used for good; cloak of invulnerability; no sidekick; Kryptonite, and an alterego. These values, beliefs, and behaviors define the specific aspects of nursing professional culture that can act as barriers to fatigue risk management programs and achieving safety culture in hospital organizations. Nurse fatigue and attributes of nurse professional culture also have implications for nurse satisfaction and retention.

Conclusions

Findings from this study further support the role of nursing professional culture as an important barrier to effectively addressing fatigue in nursing work systems. Future work is needed to identify and evaluate innovative culture change models and strategies to target these barriers.

Introduction

Worldwide, the important role of the nurse in patient outcomes is well established (Aiken et al., 2002a, Aiken et al., 2002b, Needleman et al., 2002, Tzeng et al., 2002). Nurse staffing levels, nurse education, and perceptions of work all influence the quality of care that nurses are able to provide to their patients. Addressing patient outcomes and creating a culture of safety is therefore the priority of many international organizations (IOM, 2006, Organization, 2015). A culture of safety is defined by several key characteristics including: an established, timely and anonymous reporting culture; a just culture regarding disciplinary action; diversity in employees; and a learning culture surrounding incidents (Gander et al., 2011).

Improving patient care quality through nursing care and creating a culture of safety is made more difficult due to a nursing workforce shortage internationally (Buchan and Aiken, 2008). The shortage is attributed to not only a deficit in qualified nurses, but also the deficit in nurses willing to work in the present practice conditions (Buchan and Aiken, 2008). Addressing nurse workforce issues through better nursing work system design may be a critical mechanism for improving both nurse and patient outcomes.

One modifiable factor in the nursing work system, which affects patient and nursing outcomes, is fatigue. Fatigue arises in workers in response to excessive demands from work tasks, environment, and organization, and can interfere with workers’ physical and cognitive abilities and performance (Barker Steege and Nussbaum, 2012, Rogers, 2008). As defined, fatigue is a consequence of sub-optimal system design. High demands, such as those related to long work hours, circadian disruption, increasingly complex and high acuity patients, and insufficient staffing ratios, are associated with nurse fatigue (Smith-Miller et al., 2014, Steege et al., 2015).

Previous studies have shown high prevalence of fatigue among hospital nurses (Barker and Nussbaum, 2011b, Smith-Miller et al., 2014). Nurses who are fatigued may have decreased reaction time, attention to detail, and problem-solving ability, which contributes to increased risk for errors and injury (Barker and Nussbaum, 2011a, Rogers, 2008). Given this definition, prevalence, and associated consequences, it is important to address fatigue. Nursing organizations around the world have released position statements and guidelines to address nurse fatigue and promote a safety culture through a joint responsibility shared between the healthcare organization and individual nurses (American Nurses Association, 2014, Registered Nurses’ Association of Ontario, 2011).

Implementing organizational strategies and policies to reduce fatigue and promote healthy workplace practices is the most important step in addressing nurse fatigue and reducing associated consequences (Smith-Miller et al., 2014). These strategies and policies, such as scheduled duty free breaks, strategic napping, educating employees on fatigue prevention, and implementing scheduling guidelines have been recommended in literature (Smith-Miller et al., 2014) and included in interventions to address fatigue (Scott et al., 2010a, Smith-Miller et al., 2016). However, many organizations have reported challenges in implementing these strategies in nursing work systems and promoting a safety culture (Lothschuetz Montgomery and Geiger-Brown, 2010, Smith-Miller et al., 2014). Specifically, nurses’ resistance and emotional difficulty in engaging in duty-free breaks or taking a strategic nap have acted as barriers to fatigue countermeasures (Dean et al., 2006, Patterson et al., 2011, Scott et al., 2010b). Elements of individual nurses’ professional identity and motivation as well as the organizational culture within hospitals have also been identified as potential barriers to addressing nurse fatigue (Steege and Dykstra, 2016).

In order to combat these barriers to fatigue risk management, Gander et al. (2011) recommend an understanding of culture surrounding fatigue in the work environment. Extending beyond the professional identity of a nurse or the organizational culture of a hospital, professional cultures have been identified for different health care professions, including nursing, and include distinct values, beliefs, customs, and behaviors (Hall, 2005). Socialization to the nursing professional culture begins during training, and individual alignment with these professional values is linked to job satisfaction, career development and retention (Hall, 2005, Yarbrough et al., 2016). Nurses find meaning when they are able to practice and care for their patients in a way that aligns with their own professional identity and the values of the nursing professional culture (Baumann et al., 2001). Nursing professional culture may also affect the design and implementation of programs to address fatigue in nursing work systems. For example, Lothschuetz Montgomery and Geiger-Brown (2010) point to the lack of awareness that nurses show concerning their own fatigue and its negative effects as a potential barrier to effective implementation of fatigue management programs.

Given the definition of occupational fatigue as arising in response to excessive demands from work tasks, environment, and organization, as well as the challenges noted in the literature related to implementing and sustaining effective fatigue management programs in nursing, there is a need to better understand the factors contributing to or preventing nurse fatigue, and to identify barriers and facilitators to nurse coping in hospital work systems. The overall aim of the Characterizing Fatigue and Coping Strategies in Hospital Nurses Study was to explore barriers and facilitators within the hospital nurse work system to nurse coping and fatigue. The Systems Engineering Initiative for Patient Safety (SEIPS) model (Carayon et al., 2006b) was selected as the theoretical framework to account for the complexity of the work system and its relationship to nurse, patient, and organizational outcomes. The SEIPS model has been widely used to characterize the design of healthcare work systems and investigate the influence of the work system on processes, and employee and patient outcomes (Carayon et al., 2014, Holden et al., 2013). The model has also been used to identify barriers and facilitators to performance in nursing work systems (Gurses and Carayon, 2009, Gurses et al., 2009). SEIPS integrates a work system model and balance theory to define five components of the work system structure: person (in this case the nurse), tools and technology, tasks, environment, and organization (Carayon et al., 2006b, Carayon and Smith, 2000).

Using the SEIPS model as a framework, data analysis using directed content analysis (Hsieh and Shannon, 2005) identified multiple themes describing sources of fatigue and barriers and facilitators to coping within each of the components of the work system structure. For example, patient room layout is a theme aligned with the physical environment component of the SEIPS work system structure that nurses identify as contributing to their fatigue, whereas break room layout was identified as a theme related to the physical environment component that can act as a barrier or facilitator to coping with fatigue. All of these themes are presented elsewhere (Steege and Dykstra, 2016). However, during data analysis for the Characterizing Fatigue and Coping Strategies in Hospital Nurses Study, several themes emerged that did not directly map onto the SEIPS model, but added important new insight into our understanding of the relationships between nursing professional culture and fatigue.

In spite of a growing recognition of the role of culture in addressing fatigue and managing associated risks to patient and nurse outcomes, the authors have been unable to identify any studies that specifically characterize the relationship between nursing professional culture, fatigue and the consequences of fatigue related to the nursing workforce. Existing studies have pointed to nurse culture broadly as a potential barrier to addressing fatigue (Smith-Miller et al., 2014). However, an understanding of the underlying concepts within nursing professional culture that specifically impact fatigue and the effectiveness of fatigue risk management systems is lacking. Therefore, the purpose of this paper is to describe the emergent themes from the Characterizing Fatigue and Coping Strategies in Hospital Nurses Study that did not fit with the SEIPS model and offer important additional insight into the relationship between fatigue and nursing professional culture. By better understanding nurse perceptions of the importance of fatigue and its relationship to professional culture and the nursing workforce, we can guide future work to develop and implement effective fatigue monitoring and risk management programs.